Acute pituitary apoplexy complicating a pituitary macroadenoma

Abstract

Pituitary apoplexy is a rare but potentially life-threatening condition caused by either haemorrhage or infarction of the pituitary gland. In most cases, a pre-existing pituitary macroadenoma is present. Patients present with the clinical syndrome of headache, visual defects or ophthalmoplegia, altered state of consciousness and variable endocrine deficits. Case historyA 49-year-old man presented to the emergency department with headaches, visual disturbances and severe hypotension. On examination, a left temporal hemianopia was found. His GCS was 15/15 and there were no other cranial nerve deficits. Laboratory investigations revealed decreased cortisol, thyroid stimulating hormone, prolactin, testosterone and adreno-cortico-thyrotropic hormone levels. He was also hyponatraemic.A clinical diagnosis of pituitary apoplexy with severe hypopituitarism was made, and the patient had immediate fluid and electrolyte replacement, hydrocortisone and T4 replacement. The patient was reluctant to undergo surgery and was initially managed with medical therapy. Imaging findingsOn MR investigation, a sella and supra-sella mass showing mixed signal intensity was found (Figs 1 -3). Subsequent imaging to plan for transsphenoidal surgery included a CT scan of the skull base and brain, done 3 months after the initial diagnosis, and it was then discovered that the sella mass had decreased in size. Further MR imaging a week after the CT scan and again 2 months later (Figs 4 -6)